Ob-Gyn Coding Alert

Warning: If you have to ask yourself if your documentation is "ethically" correct, then it probably isn't.

If a patient presents to your practice complaining she is unable to get pregnant, you shouldn't automatically assume that you'll be sacrificing payer reimbursement for this visit. Focusing on symptoms rather than 628.9 (Infertility, female; of unspecified origin) can make all the difference in how payers view your claims.

Get to the Crux of the Problem

Most insurance carriers will not reimburse for infertility treatments, and many payers balk when the word "infertility" pops up.

"Infertility services always require intensive review prior to a patient's visit," says Cheryl Ortenzi, CPC, billing and compliance manager of BUOB/Gyn in Boston. "In most cases, coverage is very specific. You have to verify coverage or lack thereof and review that with the patient so that everyoneunderstands who is paying for these services."

Good advice: Collect payment up-front for either the whole procedure (if the patient doesn't have any infertility benefits, such as for tubal reversal cases) or for their estimated portion (if the patient does have some coverage), experts say. Even if the only reason for the visit is "I can't get pregnant," some payers will cover the first or second visit, and "some payers will cover services that determine the condition of infertility," says Arlene Smith, CPC, CCS-P, health insurance coding specialist at Washington State Medical Association in Seattle.

This is your opportunity to maximize ethical reimbursement by following two guidelines:

1. Stick to the Presenting Symptoms

"Generally, the initial 'infertility' visit isn't really about the infertility because the cause of infertility is rarely known. The patient has an initial symptom or complaint that is the primary diagnosis or reason for this visit," says Cindy Foley, billing manager for three ob-gyn practices in Syracuse, N.Y.

In other words, infertility issues may never enter the picture if your ob-gyn effectively treats a patient's presenting symptoms. You should educate your physicians to document the patient's condition(s) using terminology that includes specific diagnoses as well as symptoms, problems or reasons for the encounter. Keep in mind: You cannot report diagnosis codes for conditions your ob-gyn merely "suspects."

Example: A woman with pelvic pain (625.9, Unspecified symptom associated with female genital organs) comes in for an appointment, and the physician focuses on this problem. The doctor discusses infertility as a secondary symptom because the patient's more urgent problem is her pelvic pain.

Solution: The ob-gyn's assessment and testing reveal the patient has endometriosis (617.0, Endometriosis of uterus), and the treatment plan is surgery. In this case, you should report the initial E/M service as a consultation (99241-99245) if the patient's primary-care physician has requested the ob-gyn's opinion, experts say. But since Medicare no longer pays for consultation, check with your payer to ensure that they still do.

On the other hand, if the patient initiated the service, you would submit an office visit code (99201-99205 for new patients, and 99211-99215 for established patients). Be sure to submit 625.9 as the primary diagnosis. For subsequent visits once the physician diagnoses endometriosis and the surgical treatment, you should use 617.0 as the primary diagnosis.

Once the ob-gyn treats the endometriosis, many women become pregnant right away, and fertility never becomes an issue. In fact, the ob-gyn's documentation never need mention infertility, except perhaps as a secondary diagnosis or when the patient specifically indicates she is seeking care because she cannot get pregnant.

"However, if the main reason for the visit is an inability to conceive or a history of infertility, this will be a cause for claim denials," Smith says.

Watch out: Ob-gyns often rely heavily on patient histories during the first visit, and any physician will likely include a discussion of pregnancy and fertility issues as part of this history. Don't let payers bully you by saying that this indicates treatment for infertility. You are correct to report other symptoms as diagnosis codes as long as the physician focuses the documentation on those issues.

Beware: Documenting according to what payers will pay is a major gray area and could land you in trouble. If you have to ask yourself if your documentation is "ethically" correct, then it probably isn't.

2. Avoid Downcoding Consultations

You may be tempted to code for an initial infertility visit as an office visit, but this may not be the case. Frequently, a woman's primary-care physician will refer her to your ob-gyn. If this is the case, you may get paid for a consultation (99241-99245) as long as the ob-gyn documents the required components.

Remember to check for the five "R's" -- reason, request, render, report and return. For the visit to qualify as a consultation, the patient's primary physician must determine the reason for a consult and request the opinion of your ob-gyn. The ob-gyn must render an opinion based on the review the of the patient's history and exam (if necessary). Finally, the ob-gyn must then report his findings and and recommendations and return the patient back to the requesting doctor.

Example: A woman with irregular menses (626.4, Irregular menstrual cycle) and cystic acne (706.1, Other acne) presents to your ob-gyn at the request of her primary physician. The primary physician suspects ovulatory dysfunction or polycystic ovarian syndrome (PCOS) and would like your ob-gyn's opinion. After a problem-focused history and exam and some diagnostic testing, the ob-gyn determines that the patient does indeed have PCOS (256.4, Polycystic ovaries). The ob-gyn discusses infertility only as a secondary symptom during the course of the history. After the visit, the ob-gyn sends a report to the requesting physician outlining the findings and proposed course of treatment.

Solution: In this case, you should report a consultation based on the extent of service the documentation indicates. Right now, you probably have moderate medical decision making but only a problem focused history and exam. Therefore, this would be a level one consultation (99241). You should include as diagnoses 256.4, 626.4, 706.1. You will list the 256.4 as your primary diagnosis because this is more specific than a diagnosis of irregular periods and you always code what you know at the end of the visit if it is more specific than the original reason for the visit.

Heads up: Be careful not to use only 256.4 because carriers often lump this with infertility treatment and may refuse to pay.

Keep in mind: Why the primary physician referred the patient is not always the appropriate ICD-9 code at the end of the visit. If the family physician referred the patient for suspected fibroids (218.x) causing infertility, and the ob-gyn does a sonogram that does not show any fibroids, you should not use fibroids as your finding.

ICD-10: When your coding system changes, you'll have to adjust how you use the codes mentioned in this article. Here is how these codes expand in 2013:

• 628.9 will become N97.9 (Female infertility, unspecified)
• 625.9 will become N94.89 (Other specified conditions associated with female genital organs and menstrual cycle), or R1Ø.2 (Pelvic and perineal pain)
• 617.0 will become N8Ø.Ø (Endometriosis of uterus)
• 626.4 will become N92.5 (Other specified irregular menstruation) or N92.6 (Irregular menstruation, unspecified)
• 706.1 will become L7Ø.Ø (Acne vulgaris), L7Ø.1 (Acne conglobata), or L7Ø.8 (Other acne)
• 256.4 will become E28.2 (Polycystic ovarian syndrome)